1. Utilizing Conservative Treatment Options in the Management of Neuromusculoskeletal Disorders George Pasquarello, DO, FAAO East Greenwich Spine & Sport East Greenwich, RI

2. Objectives  Understand multiple conservativetreatment options for various painconditions.  Identify appropriate patients for referralto specialty care.  Explain the Osteopathic approach toevaluation and management of patientswith neuromusculoskeletal disorders

3. Osteopathic Medicine

4. History A.T. Still, M.D. Dissatisfied with the practice of medicine in the 1800’s “Cure” was often worse than “illness” Medicine is “disease based” not “health based” Still loses three children to meningitis Osteopathic concept is created based on concepts of promoting wellness and supporting the body’s inherent ability to heal itself Not accepted by the medical community Still founds the Osteopathic profession in 1874

5. Osteopathic Principles The body is a unit The body has self-healing and self- regulating mechanisms Structure and function are interrelated Rational treatment is based on these principles

6. Osteopathic Manipulative Medicine A system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery and obstetrics, and emphasis on the interrelationships between structure and function, and an appreciation of the body’s ability to heal itself.

7. Osteopathic Manipulative Treatment The therapeutic application of manually guided forces by a physician to improve physiologic function and/or support homeostasis.

8. Somatic Dysfunction Impaired or altered function of related components of the somatic system: skeletal, arthroidial, and myofascial structures, and related vascular, lymphatic and neural elements.

9. Somatic Dysfunction Parameters The position of a body part as determined by palpation and referenced to its adjacent defined structure. The directions in which motion is freer. The directions in which motion is restricted.

10. Types of Somatic Dysfunction Acute – tenderness, edema, inflammation Chronic – fibrosis, contracture, parasthesias Secondary – subsequent to other etiologies

11. Pathophysiologic Models Biomechanical Respiratory/Circulatory Neurological Behavioral/Psychological Bioenergy

12. Structural Exam Gait evaluation Postural evaluation Regional exam Segmental exam Static palpation Dynamic palpation/motion testing

13. Why Use OMT? Musculoskeletal pain Decrease impact of structural dysfunction on body systems Improve respiratory mechanics Improve venous and lymphatic drainage Support homeostasis Optimize function

14. Technique Types Active – patient voluntarily performs a physician directed motion. Passive – patient refrains from voluntary muscle contraction. Direct – engages the restrictive barrier and then carries dysfunctional component into the restrictive barrier. Indirect – disengages the restrictive barrier and moves the dysfunctional component away from the restrictive barrier until tissue tension is equal in all planes.

15. Techniques Thrust Technique ( HVLA ) Articulatory ( LVHA ) Counterstrain Muscle Energy Myofascial Release Facilitated Positional Release Lymphatic Technique Soft Tissue Treatment Visceral Manipulation

16. Factors Affecting Choice of Technique Physician’s skills Patient preference Risk factors/comorbidities Acute vs Chronic problem Patient’s ability to cooperate –Direct vs Indirect technique Type of somatic dysfunction –Soft vs hard end-feel

17. Adjunctive Treatments Exercise Postural re-education Counseling Medications Injection techniques Surgery

19. Injections: Prolotherapy and Platelet Rich Plasma

20. Definitions Prolotherapy stimulates healing of injured ligaments, tendons and joints by injecting irritant solutions to encourage repair of damaged tissue. Platelet Rich Plasma facilitates healing of injured ligaments, tendons and joints by separating and concentrating the healing components in the patient’s own blood and injecting the solution (PRP) into the injured area.

21. History Hippocrates described insertion of searing needles into the anterior capsule of the shoulder in javelin throwers. 1837 – Valpeau described the use of scar formation for hernia repair. “Sclerosis” 1937 – Earl Gedney, D.O. injects ligaments of hypermobile SI joints. “Sclerotherapy”

22. History 1954- Kingsley studied the effects of Platelet Rich Plasma on clotting 1970-80s- Significant research on platelet function and development of mechanisms to separate and concentrate platelets 1987- PRP used during cardiac bypass to limit intra-operative bleeding. 2000- PRP used in dental and ENT surgery 2003- PRP use in orthopedic surgery and sports medicine

23. Wound Healing

25. Wound Healing has distinct phases that overlap in time.

26. Inflammation Phase Macrophages control wound healing -Phagocytosis -Enzymes Collagenase Elastase

27. Granulation Phase Fibroblasts differentiate to proto-myofibroblasts which pull the wound together

28. Remodeling Phase

30. structure

31. Remodeling Phase Final repair is not distinguishable from the original tissue by any analytical means. There is no scar tissue. This process gives animals the resources to repair minor injuries in such away that they will have lost no capability to survive.

32. Remodeling Phase To complete healing of ligament and tendons, movement and loading of the tissue is critical to a good outcome. There is period of vulnerability when the curve of wound healing is plotted against pain and ligament strength. The period of vulnerability is proportional to original severity of injury and expected demand.

33. Remodeling Phase

34. Chronic Enthesis Injuries Consequence of chronic stress at enthesis is tissue micro trauma with altered or incomplete tissue repair. Orderly phased wound repair is absent or aborted in these areas of micro trauma because of hypoxia. This is enthesopathy or tendinosis.

35. Enthesopathy & Tendinosis Ligament and tendon changes include

36. Enthesopathy & Tendinosis Enthesis is the most richly innervated region of a ligament or tendon. C and A  pain fibers have naked terminals.

37. Impact of NSAIDs and Corticosteroids: Incomplete wound healing

38. Wound Healing References Banks, A.R., “A Rationale for Prolotherapy”, J. Orthopedic Medicine 13 (3), 54-9 (1991) Benjamin M, Evans EJ, Copp L. The histology of tendon attachments to bone in man. Journal of Anatomy 149:89-100, 1986. Clark RAF, Henson PM (eds). The molecular and cellular biology of wound repair 2nd ed, Plenum Press, New York, 1996. Hargreaves KM. Mechanisms of pain sensation resulting from inflammation. In Sports Induced Inflammation, ed. Leadbetter WB, Buckwalter JA, Gordon SL. Am Ass Orthopedic Surg. Park Ridge IL, 1990.) Mauch C. Hatamochi A, Scharffetter K, Krieg T. Regulation of collagen synthesis in fibroblasts within a three-dimensional collagen gel. Exp Cell Res 178:493-530, 1988. Saklatvala J. Glucocorticoids: do we know how thy work? Arthritis Res 4:146-150, 2002. Simon AM, Manigrasso MB, O’Connor JP. Cyclo-oxygenase 2 function is essential for bone fracture healing. J Bone Mineral Res 17:963-977, 2002. Tomasek JJ, et al. Myofibroblast and mechanoregulation of connective tissue remodeling. Nat Review Molecular Cell Biology 3, 349-363, 2002.

39. Causes of Ligament Laxity Incomplete wound healing Recurrent trauma (overuse injuries) Overwhelming tissue trauma Hormonal deficiencies: thyroid, estrogen, testosterone or hGh Nutritional deficiencies

40. Overlap of Ligament Laxity and Tendinosis

41. Tendon and ligament instability is not a local phenomena.

42. Response to ligament laxity Muscles try to support joints Increased work load causes early fatigue Persistent muscle firing and fatigue causes atrophy Inability to compensate causes chronic fatigue and pain

43. Signs of Ligament Laxity Pain – local/referred Joint hypermobility Spasm of associated muscles Trigger points in associated muscles Weakness/atrophy of associated muscles Somatic dysfunction Morning stiffness (it’s not arthritis!)

44. Prolotherapy Inject injured ligaments or tendons Encourage activity to stress the lines of force through the tissue Avoid NSAIDs for 4 days pre and post injection Analgesics for pain (usually narcotics for the first three to five days) 3-6 sessions are typical at 3-4 week intervals Appropriate rehabilitation

45. Rehabilitation Throughout injection sessions, treat underlying somatic dysfunction. Add stretching, strengthening and proprioceptive retraining. Postural retraining and behavior modification for recurrent injury. EMG biofeedback may be useful in old injuries.

46. Common Problems Responding to Prolotherapy Joint instability: Ankle, knee, hip, sacroiliac, shoulder, wrist and digits “Fibromyalgia”, i.e. tendonosis Spinal pain due to tendonosis or ligament laxity Persistent post MVA pain, occipital headaches Piriformis syndrome

49. Platelet Rich Plasma Concentrated autologous blood products injected into an injured enthesis to stimulate the wound repair process. Similar principle as prolotherapy. Advantage: use of autologous blood products. Disadvantage: additional equipment and time needed for solution prep.

51. Platelet Rich Plasma Prep

52. Platelet Rich Plasma Injection

53. Injections: Epidural Steroid Injections, Facet Injection and Radiofrequency Ablation

56. Radiofrequency Ablation